Category Archives: Independent Medical Examinations (IME)

The Centers for Medicare and Medicaid Services recently released a treasure trove of 2012 Medicare payment data on 880,000 health care providers nationwide.

Intended to increase healthcare transparency, the data represents Medicare Part B claims totaling $77 billion in medical billings. Doctor visits, laboratory tests, and other treatments provided outside of a hospital setting are included in the database.

Payment history for 6,000 services and procedures is now available at the level of individual health care providers, including the identification of doctor names. Dollar amounts disclosed include Medicare reimbursements, as well as patient payments in the form of deductibles or co-insurance. Procedures on fewer than 10 Medicare recipients conducted by a single provider are excluded.

The U.S. Government Accountability Office (GAO) reports that 49 million elderly and disabled Americans received more than $555 billion in Medicare services during 2012. Fraud is an acknowledged element of the Medicare program, and the GAO estimates at least $44 billion in annual Medicare disbursements are made improperly.

Ophthalmologists and radiation oncologists are medical specialties that stand out as receiving high payment levels, relative to total national Medicare spending, according to the Wall Street Journal.

Dr. Salomon Melgen, a Florida ophthalmologist, received the highest level of 2012 Medicare reimbursement in the country, according to the Tribune Newspapers. Melgen’s billing practices and political connections have been the subject of a grand jury investigation.

Another Florida doctor, Ocala-based cardiologist Asad Qamar, took second place nationally with $22.9 million in 2012 Medicare payments, also as reported by the Tribune Newspapers.

A federal injunction, granted at the urging of the American Medical Association, has kept this data private since 1979. The Wall Street Journal published an investigative series on physician reimbursements in 2011, and in the following year its parent Dow Jones & Co. took legal action seeking database access. The injunction was ultimately overturned by a Florida judge.

According to a June 18, 2012 FBI press release from Wifredo A. Ferrer, United States Attorney for the Southern District of Florida, John V. Gillies, Special Agent in Charge, Federal Bureau of Investigation (FBI), Miami Field Office, José A. Gonzalez, Special Agent in Charge, Internal Revenue Service, Criminal Investigation Division (IRS-CID), and Jeff Atwater, Chief Financial Officer, Florida Department of Financial Services, 11 others are charged in two separate indictments for involvement in a staged accident PIP fraud scheme.

From the FBI press release:

In two separate indictments, defendants Obelio Rodriguez, a/k/a Ovy, 43, formerly of West Palm Beach, Maria Molina, a/k/a Cary, 41, of West Palm Beach, Yuliet Tapanes, 25, of West Palm Beach, Moises Madrid, 40, of Orlando, a licensed massage therapist, Dagoberto Milian Lopez, a/k/a Lavadora, 56, formerly of West Palm Beach, Amaurys Hernandez, a/k/a El Manco, 40, of West Palm Beach, Gilda Garcia, a/k/a Hilda, a/k/a La Que Carta, 49, of Greenacres, Javier De La Caridad Troncoso, 45, of Lake Worth, Ana Ovando, 42, of Lake Worth, and Janice Velez, 39, of West Palm Beach, were each charged with one count of conspiracy to commit mail fraud, in violation of Title 18, United States Code, Section 1349. Defendant Jennifer Adams, 38, of Boca Raton, a licensed chiropractic physician, was charged in an Information with one count of conspiracy to commit mail fraud, in violation of Title 18, United States Code, Section 1349. The charge carries a maximum sentence of 20 years’ imprisonment.

Those involved were allegedly involved in recruiting individuals to participate in staged automobile accidents and instructing participants on how to conduct accidents, what to tell responding police officers, insurance company representatives and independent medical examination (IME) physicians, how to collect police reports, and what clinic to go to for treatment, even though the participants did not need treatment.

Records also indicate the defendants prepared fraudulent insurance documentation and fraudulent PIP Automobile Insurance Claims for chiropractic and massage therapy treatments for the staged accident participants, claiming that that the treatments were medically necessary and that the patients had received the treatments when, in fact, the treatments were not necessary and usually not received.

This week the Florida State Massage Therapy Association sent a request to Governor Rick Scott to veto the recently amended Florida PIP law. In their letter the FSMTA addresses some of their concerns including:

Patients in Emergency Rooms – with the new mandate, Emergency Rooms will see an unnecessary increase at their facilities – potentially preventing those with “real” emergencies due to the influx of automobile accident patients.

Type of care – massage therapy is a non-pharmaceutical approach to health and healing. Based on the mandate, this option does not appear to be considered.

More details are emerging about the company we first mentioned on March 30, 2012 offering to send medical doctors or osteopathic physicians to chiropractors’ offices to examine patients and fill out paperwork that could possibly qualify them as an “emergency” to attempt to qualify patients for the maximum $10,000 personal injury protection benefit.

The Associated Press reports:

Darrell Stollings, chief executive officer of the medical staffing and placement firm, said Wednesday that he’s not trying to skirt conditions of the new legislation although he agreed that his flier was an eye-catcher.

“We have physicians who are available to look at the patient to make sure that patient is medically needing of that (chiropractic) service,” Stollings said. “If not, they don’t get that service.”

Other saw it differently.

“The governor hasn’t even signed the bill yet and some firm is sending this thing around?” asked Rep. Jim Boyd, a Bradenton Republican who sponsored the legislation. “It’s very brazen and I think action will be taken if someone is trying to do something that is not acceptable.”

Boyd said he had already spoken to officials from the Department of Health and Division of Insurance Fraud about checking into the validity of the Tampa company’s overture to chiropractors.

Addressing the marketing campaign that arose only three weeks after the new PIP law was passed, James Quiggle, communications director for the Washington-based Coalition Against Insurance Fraud commented, “This flier may be perfectly legal, but chock full of potential for fraud and abuse.”

Only weeks after the Florida Senate passed an amended PIP law, businesses have begun to emerge offering “rent-an-M.D.” services to circumvent the 2012 Statute’s $2,500 cap on medical benefit reimbursement for chiropractic treatment.

The recently amended PIP law caps reimbursement to $2,500 for chiropractic treatment under ordinary circumstances. However, if an Insured both (1) receives treatment within 14 days in an ambulance or hospital, or with a physician, osteopathic physician, chiropractic physician or dentist and (2) has a physician, osteopathic physician, dentist, or a supervised physician’s assistant or advanced registered nurse practitioner determine that the insured has an “emergency medical condition,” then there are $10,000 in benefits available for chiropractic treatment.

Services are already beginning to emerge offering to send an MD or DO to chiropractic facilities to satisfy the “emergency medical condition” requirement of the new statute. One ad claims:

“Medical On Demand” can send a MD/DO to your facility to see your PIP patients. Our physician wil do assessments, fill out and sign forms that state the Insured has an emergency medical condition.

Follow FL PIP Guide for for additional updates on the changes and reactions to Florida’s recently amended PIP laws.

On the final day of the 2012 Florida legislative Session, the Florida Senate passed (22-17) a modified PIP/No-Fault law with significant changes from the 2008 version of the statute.

According to Senator Mike Haridopolos, the 2012 legislative session was an effective one. “[T]he legislature also made sweeping changes to the state’s personal injury protection (PIP) medical benefits under the No-Fault law and laws related to motor vehicle insurance fraud. Currently, PIP is wrought with fraud and abuse, and this legislation, sponsored by Senator Joe Negron (R-Stuart), reforms PIP from start to finish and will end the cycle of rising auto insurance premiums.”